Outcome of Early Versus Late Surfactant Therapy in Preterm Neonates with Respiratory Distress Syndrome at a Tertiary Care Centre

Background: Respiratory distress syndrome (RDS) or hyaline membrane disease (HMD), has been recognized as the most common co-morbidity of prematurity. Prematurity and RDS largely contribute to early neonatal morbidity and mortality. With adequate antenatal steroid and early continuous positive airway pressure, early surfactant therapy improve survival outcome.Material & Methods:Prospective interventional study included newborns with prematurity 28-36 weeks(GA) with clinical Respiratory distress syndrome and birth weight(BW)>650 gm. All subjects were preferably provided early surfactant therapy (within 2hours after birth). Surfactant (survanta) was delivered by INSURE technique (Intubate- Surfactant administration- Extubate) and only those who required further respiratory support were ventilated. Records on birth weight, gestational age, timing of therapy (early/late), sepsis, complications, and survival/death outcome were collected and data was analyzed using SSPS version 20 software.Results:Out of 76 neonates (42 male, 34 female), 46 received early surfactant therapy and 30 obtained it late; Although mortality was observed with both early(36.66%) and late therapy(63.33%), there was significantly higher survival with early therapy. higher mortality occurred in lower Birth weight(LBW) /Gestational age (GA) subgroups. Culture positive sepsis was found in 52.6% with higher association with late therapy . Hypotension was most common complication with late intervention , whereas there was no difference for pulmonary haemorrhage or apnea.Conclusion:Early surfactant administration improved survival with minimal complications in RDS except for extremely premature/LBW babies.

Effect and security of minimally invasive surfactant therapy in neonatal respiratory distress syndrome / 中华实用儿科临床杂志

Objective@#To explore the effect and security of minimally invasive surfactant therapy (MIST) in treatment of preterm infants with neonatal respiratory distress syndrome (NRDS).@*Methods@#A total of 48 pretrm infants with gestational ages between 30-36 weeks diagnosed with NRDS in Guangzhou Women and Children′s Medical Center from January 2017 to January 2018 were randomly divided into MIST group (23 cases) and intubation-surfactant-extubation+ continuous positive airway pressure ventilation (INSURE) group (25 cases) by adopting random number table method.The patients in MIST group were put on nasal continuous positive airway pressure (nCPAP) and a thin vascular catheter was inserted through the vocal cords under direct vision with direct laryngoscope then infused pulmonary surfactant(PS) into the lung; the patients in INSURE group were endotracheally intubated and infused with PS into the lung through endotracheal tube with positive airway pressure, then extubated and put on nCPAP again.The incidences of adverse reactions and various complications related to the 2 groups were observed.@*Results@#There were no significant differences between 2 groups in oxygen saturation decrease(26.1% vs.36.0%), bradycardia (13.0% vs.24.0%) and reuse PS (8.7% vs.4.0%) (all P>0.05). There were no significant differences between 2 groups in noninvasive ventilation time [8 d (5.5-12.5 d) vs.7 d(5.0-14.0 d)], total oxygen intake time [12 d(7.0-26.5 d) vs.10 d(10.0-23.0 d)] and length of hospital stay [(34.22±16.06) d vs.(30.88±14.35) d] (all P>0.05). There was no death or intraventricular hemorrhage in both groups, and there were no significant differences between 2 groups in the incidences of pneumothorax (0 vs.4.0%), bronchopulmonary dysplasia (21.7% vs.16.0%), retinopathy of prematurity (21.7% vs.12.0%) and necrotizing enterocolitis (21.7% vs.12.0%) (all P>0.05).@*Conclusions@#MIST technique is a safe and effective method to administrate surfactant in preterm infants with NRDS.In the NRDS patients who do not need intubation and mechanical ventilation, MIST technique can be used to administrate PS.

Clinical Outcomes of Minimally Invasive Surfactant Therapy via Tracheal Catheterization in Neonates with a Gestational Age of 30 Weeks or More Diagnosed with Respiratory Distress Syndrome

PURPOSE: Minimally invasive surfactant therapy (MIST) is currently used as a method of surfactant replacement therapy (SRT) for the treatment of respiratory distress syndrome (RDS) in preterm infants with a gestational age of less than 30 weeks. However, few studies have been conducted on MIST in neonates with a gestational age of 30 weeks or more. In this study, we compared MIST with endotracheal intubation as a rescue SRT for spontaneously breathing neonates with a gestational age of 30 weeks or more who were diagnosed with RDS. METHODS: We investigated the clinical characteristics of spontaneously breathing neonates admitted to the neonatal intensive care unit of the Inje University Sanggye Paik Hospital from January 1, 2014 to December 31, 2016. These neonates were born at a gestational age of 30 weeks or more and were diagnosed with RDS. The neonates who were administered surfactant by MIST were categorized into the MIST group (n=16) and those who underwent endotracheal intubation were categorized into the control group (n=45). Thereafter, the clinical characteristics between the groups were compared. RESULTS: Compared to the control group, the MIST group was less likely to require mechanical ventilation within 72 hours (P < 0.001). The frequency of bradycardia during SRT was also low in the MIST group (P=0.033). CONCLUSION: MIST is considered relatively feasible and safe for treating RDS for reducing the need for mechanical ventilation and decreasing the occurrence of bradycardia during surfactant administration in neonates with a gestational age of 30 weeks or more.

Minimally Invasive Surfactant Therapy / 대한주산의학회잡지

For many years preterm infants with respiratory distress syndrome have been managed with a combination of intubation and surfactant replacement therapy. It is now recognized that applying noninvasive ventilation (NIV) such as nasal continuous positive airway pressure (CPAP) in preterm infants is a reasonable alternative to early intubation after birth. Recently, nasal CPAP has shown a benefit with a small reduction in the risk of the combined outcome of death or bronchopulmonary dysplasia. There has been an upsurge in the use of NIV as primary therapy for preterm infants, bringing with it the dilemma of when and how to give exogenous surfactant. In an effort to overcome this problem, minimally invasive surfactant therapy (MIST) to spontaneously breathing infants, allows them to remain on CPAP in first days after birth. MIST has included administration of exogenous surfactant by brief tracheal catheterization, aerosolization, laryngeal mask, and intrapharyngeal instillation. In recent clinical trials, surfactant delivery via brief tracheal catheterization was found to reduce the need for subsequent intubation and mechanical ventilation and to improve short-term respiratory outcomes. In conclusion, MIST is gentle, safe, feasible and effective to perform in preterm infants and will also be used commonly in Korea.

Outcome of surfactant therapy in a tertiary referral centre in Sri Lanka.

Objective To assess the outcome of surfactant therapy at a tertiary referral centre in Sri Lanka Design, setting and method All babies treated with surfactant at Sri Jayewardenepura General Hospital during 2007 were included in the study. Data on weight, maturity, age of ventilation, age of surfactant therapy, ventilator settings before and after surfactant, arterial blood gas results before and after surfactant, details regarding pneumothorax and pulmonary haemorrhage, duration of ventilation and chronic lung disease at 28 days, 3 months, and 6 months were collected. Data analysis was done according to maturity groups. Results Forty eight babies had surfactant therapy during the study period. The commonest indication was hyaline membrane disease (HMD) in prematures (45), followed by meconium aspiration syndrome (03). According to maturity, 22 (46%) were in 28- 33+ weeks, followed by 12 (25%) in < 28 weeks, 11 (23%) in 34-36+ weeks and 3 (6%) were >37 weeks (mature). Only 6 (12%) babies in 34-36+ weeks had transient hypoxia. None of them developed pneumothorax. Four (8%) had features suggestive of pulmonary haemorrhage 12-48 hours after surfactant replacement therapy. Four (8%) babies had chronic lung disease at 28 days of age and two of them were in babies < 28 weeks. The reduction in oxygen requirements was seen within 6 hours of therapy in 7/12, 18/22, 6/11 in < 28, 28-33+ and 34-36+ weeks babies respectively and in 12-24 hours in babies >37 weeks. There were 14 deaths comprising 5/12 of babies < 28 weeks, 5 /22 of 28-33+ weeks, 4/11 of 34- 36+ weeks. Duration of ventilation varied among the survivors; 5/7 babies of < 28 weeks needed >10 days of ventilation whereas 10/17 of 28-33+ weeks needed < 10 days of ventilation. Conclusions Reduction in oxygen requirement was seen within 6 hours of surfactant therapy in 65% of babies. Only 16% of babies who had surfactant therapy developed complications such as pulmonary haemorrhage and chronic lung disease. Duration of ventilation varied according to the maturity of the baby.

Treatment of smoke inhalation injury by delayed lung lavage with pulmonary surfactant diluent / 中华急诊医学杂志

Objective To investigate the therapeutic effects of delayed lung lavage with exogenous pulmonary surfactant(PS)diluent on endogenous surfactant system dysfunction and acute respiratory failure caused by severe smoke inhalation in rats.Method Ninety Wistar rats were randomly separated into five groups:Group I,normal control(n=14);Group Ⅲ,smoke inhalation(n=27);GroupⅢ,smoke+PS lavage+mechanical ventilation(MV),n=21;Group IV,smoke+saline lavage+MV,n=10;Group V,smoke+MV,n=18.The lungs were lavaged with 30 ml/kg normal ssdine containing 100 mg/kg PS or same volume of saline via tra cheal catheter at 2 h after smoke inhalation,then the animals were placed on a ventilator for 4 h,and observed until 24 h after injury.The arterial blood gas level,lung water volume,static lung compliance(Cst),total protein and albumin contents in bronchoalveolar lavage fluid(BALF),surface tension properties of BALF,and fatality rate at 24 h were measured.Results Smoke inhalation caused a similar acute hypoxia and severe carbon monoxide poisoning immediately in all injured groups.The animals in group Ⅱ showed acute respiratory failure,serious hish permeability pulrnonary edema,and surfactant system dysfunction.The surface tension properties of BALF and Cst were significantly improved by delayed lung lavage treated with exogenous PS diluent in group m(P<0.05).However,the lung water volume,total protein and albumin contents in BALF and the oxygenation had not significant difference between group Ⅲ and group Ⅱ(P>0.05).Conclusions Delayed lung lavage with exogenous PS diluent,at a certain extemt,restored endogenous suffactant function inhibited by smoke inhalation and improved lung function.Nevertheless,the trent could not alleviate rash permeability pulmonary edema and respiratory failure drarnatically.The expected decrease of mortality at early stage after smoke inhalation injury was not showed yet.

Effect of Nasal Continuous Positive Airway Pressure after Early Surfactant Therapy in Moderate Respiratory Distress Syndrome

PURPOSE: Early surfactant therapy with either gentle ventilation, high-frequency ventilation or aggressive weaning of mechanical ventilation are principles for the treatment of respiratory distress syndrome(RDS). We studied to determine the accessibility of noninvasive nasal continuous positive airway pressure(CPAP) rather than mechanical ventilation by invasive intubation after early surfactant therapy. METHODS: The study group consisted of 14 infants who were born and diagnosed with moderate respiratory distress syndrome and received early surfactant therapy with nasal CPAP of PEEP 5-6 cm H2O within two hours after birth in the Fatima neonatal intensive care unit for two years from January 1999 to August 2001. The control group consisted of 15 infants who were diagnosed with the disease and could be weaned from mechanical ventilator within five days after birth during the same period. RESULTS: The characteristics, the severity of clinical symptoms and laboratory findings in the two groups at birth showed no significant difference. Neither did the interim analysis of laboratory data in two groups. Of 14 infants in the study group who received nasal CPAP after early surfactant therapy, only two infants showed weaning failure with this therapy. In the response cases, duration of CPAP was five days and mean airway pressure was 5.4+/-0.5 cm H2O. Two had the complication of CPAP with abdominal distension. Final complications and outcomes in the two groups showed no signifcant difference(p>0.05). CONCLUSION: The clinical courses in the two groups showed no significant difference. Therefore, we suggest that early surfactant therapy with noninvasive nasal CPAP is a simple and safe method rather than aggressive weaning after invasive mechanical ventilation in moderate respiratory distress syndrome.

Poor response to surfactant therapy in RDS-infant with early patent ductus arteriosus.

A prospective study was conducted to evaluate the effect (Alvofact by Boehringer Ingelheim) on oxygen and mean airway pressure (MAP) requirements and improvements in the alveolar-arterial partial pressure of oxygen gradient (A-a PO2 gradient) in 32 preterm infants with respiratory distress syndrome (RDS), 16 infants in each group. The diagnosis of PDA was made in the presence of hyperactive precordium and/or a systolic murmur heard at upper left sternal border and confirmed by echocardiography when available, or by autopsy. The mean birthweight (1180 vs 1079 g,p=0.35) and the mean age at receiving surfactant (5.5hr vs 7.8hr, p 0.234) of the two groups were not statistically different but the initial severity of RDS in infants with early PDA (Group 1) was more. In Group 1, improvements in oxygen requirements were significant at 1 hr after treatment (p=0.01) but became nonsiginificant at 24 hours (p=.06). Sustained improvements in A-a PO2 gradient were found at 48 hrs (p=0.012). Improvements in MAP were significant at day 14 after treatment (p=0.03). In infants without early PDA (Group 2), improvements in oxygen requirement were significant at 30 min after treatment (p=0.027). Improvements in MAP and A-a PO2 gradient were significant at 5 min after treatment. Improvements in A-a PO2 gradient appeared nonsignificant at 48 and 72 hours when PDA was present and subsequently appeared significant again at 96 hours when PDA was closed by indomethacin. Mortality was significantly reduced (11 vs 2, p=0.003) in Group 2. Because only 9 infants in Group 1 lived longer than 28 days trends suggested a lower incidence of bronchpulmonary dysplasia in Group 2 (7 in 9 vs 5 in 14, p=0.083). In conclusion, RDS-infants with PDA prior to surfactant therepy have poor and transient responses to surfactant and were associated with higher mortality and higher incidence of brochopulmonary dysplasia. Early closure of PDA may benefit these infants.

Exogenous pulmonary surfactant replacement therapy in a neonate with pulmonary hypoplasia accompanying congenital diaphragmatic hernia: a case report

Pulmonary hypoplasia(PH) commonly occurs in association with oligohydramnios and other congenital anomalies, especially congenital diaphragmatic hernia (CDH). Pulmonary hypoplasia is an important factor, as persistent pulmonary hypertension, in the prognosis of CDH. In some reports, there is a decrement of pulmonary surfactant in PH accompanying CDH. Recently, there are some reports that exogenous pulmonary surfactant therapy is effective in experimental animal model and neonatal respiratory distress with PH. We report a case of a 5 day-old male neonate, who had shown dyspnea and diagnosed as left pulmonary hypoplasia accompanying CDH. The CDH was surgically treated and the ipsilateral PH, with intratracheal administration of exogenous pulmonary surfactant postoperatively. After exogenous pulmonary surfactant application, the left lung volume was increased on chest roentgenogram and lung perfusion scan findings, and there was an improvement in oxygenation and clinical manifestations. We suggest that postoperative exogenous pulmonary surfactant replacement therapy is effective in the case of PH and further trials are needed to clarify the optimal dose and timing of supplementation of surfactant for treatment of infants with PH accompanying CDH.